Project Summary The period following hospital discharge is a vulnerable time for patients in which poorly coordinated care and medication mismanagement are common. Suboptimal care in the peri-discharge period contributes to preventable adverse events, hospital readmission, and higher mortality, particularly in high-risk conditions such as acute coronary syndromes (ACS). Low health literacy is a prevalent risk factor for poor processes and outcomes of care, but little research has been conducted on the role of health literacy in this high-risk setting. The goal of this research is to examine how health literacy and other patient characteristics affect the quality of hospital discharge and related outcomes after hospitalization. We will test a conceptual framework that includes patient-, provider-, and system-related factors as potential mediators and moderators of these relationships. The Specific Aims are to: 1) Determine the association of health literacy with the quality of hospital discharge, including the impact on communication, preparedness for discharge, and subsequent medication management. 2) Examine the effect of health literacy and hospital discharge quality on functional status, health- related quality of life, and unplanned health care utilization 30 and 90 days after hospital discharge. 3) Examine the effect of health literacy and hospital discharge quality on mortality after hospitalization. We will perform a prospective cohort study of 3,000 adults hospitalized for ACS and discharged to home. Data collection and analyses will be grounded in a conceptual framework that relates health literacy to processes and outcomes of care. During hospitalization, we will administer a robust set of validated sociodemographic, educational, cognitive, psychological, cultural, and behavioral measures. For Aim 1, we will interview patients by telephone 2-3 days after discharge to assess the quality of hospital discharge, including measures of patient-provider communication and preparedness for discharge. For Aim 2, we will review medical records and interview patients by telephone 30 and 90 days after discharge to assess changes in functional status, health-related quality of life, and unplanned health care utilization, including Emergency Department visits and rehospitalization. For Aim 3, we will ascertain mortality using the Social Security Administration Death Master File, following patients for up to 3.5 years after enrollment. We will use multivariable path analyses and survival analyses to model the direct and indirect relationships among health literacy, other measured factors, potential mediators or moderators, and each outcome of interest. This interdisciplinary research will greatly enhance our understanding of how health literacy affects hospital discharge processes and outcomes after hospitalization. Findings will enable us to better design interventions to improve services for patients with low health literacy, as well as other high-risk groups. Knowledge gained from this study may also help improve cardiovascular outcomes and reduce literacy-related health disparities.